{"openapi":"3.0.0","info":{"version":"1.0.0","description":"Pre-service Benefit Check API: Prior Auth, Benefit Coverages, and Referral Inquiry for member services","title":"Benefit Check API"},"servers":[{"url":"https://sandbox-apigw.optum.com"}],"paths":{"/oihub/patient/benefit/check/v1":{"post":{"security":[{"oAuth":["read_healthcheck"]}],"operationId":"benefitCheck","tags":["Benefit Check"],"parameters":[{"name":"providerTaxId","in":"header","description":"Provider Tax ID","required":true,"schema":{"type":"string","example":"123456789"}},{"name":"x-optum-consumer-correlation-id","in":"header","description":"Unique UUID to track the transaction","required":false,"schema":{"type":"string","example":"4d4a8964-e5fa-42dc-a37d-12345789"}},{"name":"environment","in":"header","description":"Environment","required":false,"schema":{"type":"string","example":"sandbox"}}],"requestBody":{"content":{"application/json":{"schema":{"description":"Example for Benefit Check covering Prior Auth","properties":{"operationName":{"type":"string","description":"Name of the GraphQL operation to execute (e.g., CheckPriorAuthBenefitCoverage"},"query":{"type":"string","description":"GraphQL query"},"variables":{"description":"Variables for the GraphQL query","type":"object","properties":{"benChkInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"serviceLocation":{"description":"Service Location","$ref":"#/components/schemas/ServiceLocationInput"},"caseDetailProvider":{"description":"Case Detail Provider","items":{"$ref":"#/components/schemas/CaseDetailProviderInput"},"type":"array"},"diagnosisCodes":{"description":"Diagnosis codes","items":{"$ref":"#/components/schemas/DiagnosisCodesInput"},"type":"array"},"facilityServiceDetail":{"description":"Facility service detail","$ref":"#/components/schemas/FacilityServiceDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"required":["payerId","facilityServiceDetail","diagnosisCodes","beneficiaryDetail","serviceLocation","caseDetailProvider"]},"refInqInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"providerDetail":{"description":"Details of the provider","$ref":"#/components/schemas/ProviderDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"required":["payerId","beneficiaryDetail","providerDetail"]},"benLangInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Transaction ID from eligibility or benefit category lookup.","$ref":"#/components/schemas/BeneficiaryDetailInput"},"eligibilityTransactionId":{"description":"Transaction ID returned from eligibility or Benefit Category operation (Conditionally Required)","example":"abcdefg","type":"string"},"benefitId":{"description":"Benefit Id","example":"ben-a111-b222-c333","type":"string"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"required":["payerId","benefitId"]},"benCatgInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"searchPhrase":{"description":"Search Phrase","example":"MRI","type":"string"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"required":["payerId","beneficiaryDetail"]}}}},"type":"object","required":["query","variables"]},"examples":{"ClaimBenefits":{"summary":"ClaimBenefits","value":{"operationName":"CheckPriorAuthBenefitCoverage","query":"query CheckPriorAuthBenefitCoverage($benChkInput: CheckPriorAuthBenefitCoverageInput!) { checkPriorAuthBenefitCoverage(benChkInput: $benChkInput) { caseOutcome { casePriorAuth { requestMessages { messageText } requestOutcomeCode requestOutcomeCodeDescription requestReferenceNumber } } caseSummary { member { groupNumber memberId } placeOfServiceCode requestingProviderNPI requestingProviderTin } matchedPriorAuths { caseDecision caseServices { procedureCode serviceDecision serviceMessage } caseStatus serviceReferenceNumber } serviceOutcomes { procedureCode procedureCodeDescription servicePriorAuth { isPriorAuthOnFile messages { messageText } serviceOutcomeCode } } } }","variables":{"benChkInput":{"beneficiaryDetail":{"beneficiaryId":"M123456789","dateOfBirth":"1985-06-15","firstName":"John","lastName":"Doe","groupNumber":"G123456","serviceStartDate":"2023-01-01","serviceEndDate":"2023-01-01"},"serviceLocation":{"placeOfServiceCode":"11","claimType":"I","serviceDetail":"Medical","serviceDescription":"Scheduled"},"caseDetailProvider":[{"providerType":"Physician","providerTaxIdNumber":"123456789","providerNPI":"9876543210","providerFirstName":"John","providerLastOrOrganizationName":"Doe Clinic","address":{"line1":"1234 CHARDAVE","line2":"","city":"Hastings","state":"TX","zip":"12133","zip4":"1001"},"providerRoles":[{"role":"Requesting"}],"procedureDetails":[{"procedureCode":"99213","codeType":"CPT","isPrimary":true,"serviceStartDate":"2025-08-01","serviceEndDate":"2025-08-01","diagnosisCode":"J01.90","procedureUnitPerFrequencyCount":"1","procedureUnitOfMeasure":"UN","procedureFrequency":"1","procedureUnitCount":"1","procedureBilledChargeAmount":"100","serviceDetailDescription":"Medical"}]}],"diagnosisCodes":[{"diagnosisTypeCode":"ABK","diagnosisCode":"J01.90"}],"facilityServiceDetail":{"facilityServiceStartDate":"2025-08-01","facilityServiceEndDate":"2025-08-01","isPatientAdmitted":false,"isPatientDischarged":false},"payerId":"12345"}}}},"ReferralInquiry":{"summary":"ReferralInquiry","value":{"operationName":"ReferralInquiry","query":"query ReferralInquiry($refInqInput: CheckReferralInquiryInput!) { referralInquiry(refInqInput: $refInqInput) { referralIndicator } }","variables":{"refInqInput":{"beneficiaryDetail":{"beneficiaryId":"M123456789","dateOfBirth":"1985-06-15","firstName":"John","lastName":"Doe","groupNumber":"G123456","serviceStartDate":"2023-01-01","serviceEndDate":"2023-01-01"},"providerDetail":{"providerLastOrOrganizationName":"Doe Clinic","providerFirstName":"John","providerNPI":"9876543210"},"payerId":"12345"}}}},"PlanBenefitLanguage":{"summary":"BenefitLanguage","value":{"operationName":"CheckPlanBenefitLanguage","query":"query CheckPlanBenefitLanguage($benLangInput: CheckPlanBenefitLanguageInput!) { checkPlanBenefitLanguage(benLangInput: $benLangInput) { newBenefits benefits { benefitName benefitDetails benefitInformationSection benefitNetworkSection { costs networkStatus } limitsAndExceptions { description details } } } }","variables":{"benLangInput":{"beneficiaryDetail":{"beneficiaryId":"M123456789","dateOfBirth":"1985-06-15","firstName":"John","lastName":"Doe","groupNumber":"G123456","serviceStartDate":"2023-01-01","serviceEndDate":"2023-01-01"},"eligibilityTransactionId":"abcdefg","benefitId":"ben-a111-b222-c333","payerId":"12345"}}}},"PlanBenefitCategory":{"summary":"BenefitCategory","value":{"operationName":"CheckPlanBenefitCategory","query":"query CheckPlanBenefitCategory($benCatgInput: CheckPlanBenefitCategoryInput!) { checkPlanBenefitCategory(benCatgInput: $benCatgInput) { eligibilityTransactionId newBenefits benefitCategory { categoryName categoryDetail { benefitId benefitName benefitSummaryText } } } }","variables":{"benCatgInput":{"beneficiaryDetail":{"beneficiaryId":"M123456789","dateOfBirth":"1985-06-15","firstName":"John","lastName":"Doe","groupNumber":"G123456","serviceStartDate":"2023-01-01","serviceEndDate":"2023-01-01"},"searchPhrase":"MRI","payerId":"12345"}}}}}}},"required":true},"responses":{"200":{"content":{"application/json":{"examples":{"BenefitCheckResponse":{"summary":"ClaimBenefits","value":{"data":{"checkPriorAuthBenefitCoverage":{"caseOutcome":{"casePriorAuth":{"requestMessages":[{"messageText":"Prior authorization required for the requested service"}],"requestOutcomeCode":"1","requestOutcomeCodeDescription":"Authorization Required","requestReferenceNumber":"REQ123456789"}},"caseSummary":{"member":{"groupNumber":"M123456789","memberId":"G123456"},"placeOfServiceCode":"11","requestingProviderNPI":"9876543210","requestingProviderTin":"123456789"},"matchedPriorAuths":[{"caseDecision":"Approved","caseServices":[{"procedureCode":"99213","serviceDecision":"Approved","serviceMessage":"Prior authorization valid through 2025-12-31"}],"caseStatus":"Closed","serviceReferenceNumber":"AUTH123456"}],"serviceOutcomes":[{"procedureCode":"98941","procedureCodeDescription":"Chiropractic adjustment involving 3-4 areas of the spine","servicePriorAuth":{"isPriorAuthOnFile":false,"messages":[{"messageText":"Prior authorization required for the requested service"}],"serviceOutcomeCode":"1"}}]}}}},"ReferralInquiryResponse":{"summary":"ReferralInquiry","value":{"data":{"referralInquiry":{"referralIndicator":"Y"}}}},"BenefitLanguageResponse":{"summary":"PlanBenefitLanguage","value":{"data":{"checkPlanBenefitLanguage":{"newBenefits":true,"benefits":{"benefitName":"Hearing Aids","benefitDetails":"What are hearing aids: Electronic amplifying devices designed to bring sound more effectively into the ear.","benefitInformationSection":["text"],"benefitNetworkSection":[{"costs":"UHC Network: co-insurance after you pay the deductible. Is prior-auth needed? No","networkStatus":["Your cost if you use Network benefits"]}],"limitsAndExceptions":[{"description":"General","details":"No coverage for bone anchored hearing aids except Craniofacial anomalies."}]}}}}},"BenefitCategoryResponse":{"summary":"PlanBenefitCategory","value":{"data":{"checkPlanBenefitCategory":{"eligibilityTransactionId":"abcdefg","newBenefits":true,"benefitCategory":[{"categoryName":"MRI services","categoryDetail":[{"benefitId":"abc2fe-89b57","benefitName":"X-Ray","benefitSummaryText":"UnitedHealthcare X-Ray Program"}]}]}}}}},"schema":{"type":"object","properties":{"data":{"type":"object","properties":{"checkPlanBenefitLanguage":{"$ref":"#/components/schemas/BenefitLanguageResponse"},"checkPriorAuthBenefitCoverage":{"$ref":"#/components/schemas/BenefitCheckResponse"},"checkPlanBenefitCategory":{"$ref":"#/components/schemas/BenefitCategoryResponse"},"referralInquiry":{"$ref":"#/components/schemas/ReferralInquiryResponse"}}},"errors":{"items":{"type":"object","properties":{"code":{"type":"string","description":"Error code identifying the specific error"},"description":{"type":"string","description":"Detailed error message"}}},"description":"List of errors if occurred during Benefit Check","type":"array"}}}}},"description":"ClaimBenefits\n\n - MISSING_REQUIRED_FIELD\n
\n - Missing mandatory header field: XXXXX
\n - Missing mandatory requestField: XXXXX
\n
\n \n - INVALID_FIELD\n
\n - Invalid field: XXXXX
\n - Missing or invalid information: XXXXX
\n
\n \n - INTERNAL_SERVER_ERROR\n
\n - An unexpected error occurred while processing the request
\n
\n \n - BAD_USER_INPUT\n
\n - Variable \"$benChkInput\" got invalid value { beneficiaryId: \"123456\", dateOfBirth: \"1976-08-27\", firstName: \"\", lastNamee: \"\", groupNumber: \"NMOFEX\", familyIndicator: \"Y\", serviceStartDate: \"2024-01-20\", serviceEndDate: \"2024-01-20\" } at \"benChkInput.beneficiaryDetail\"; Field \"lastNamee\" is not defined by type \"BeneficiaryDetailInput\". Did you mean \"lastName\" or \"firstName\"?
\n
\n \n
\n
\nReferralInquiry\n\n - VALIDATION_FAILED\n
\n - Invalid format: dateOfBirth
\n - Invalid format: Service Start Date
\n - Invalid format: Service End Date
\n - Need additional inputs to perform the search
\n - Invalid Coverage type
\n - Incorrect Timeline indicator. Allowed values - 1,2,3,4.
\n - Start Date must be within 6 years and End date should not exceed more than 1 year.
\n - Last Date of Service must be on or after the First Date of Service.
\n - Provider LastName Missing.
\n - One of Provider NPI, Provider Tax ID, or Provider MPIN must be provided
\n - Start Date must be within 7 years and End date should not exceed more than 1 year.
\n - Search by name and DOB is not allowed for AARP members. Please enter a member ID to proceed.
\n - Bad request - Your search period is greater than 12 months.
\n - Platform not supported for the consumer.
\n - Missing serviceStartDt. serviceStartDt and serviceEndDt are required to proceed with the search.
\n - Missing serviceEndDt. serviceStartDt and serviceEndDt are required to proceed with the search.
\n - To check eligibility and benefit information for USHG please visit https//provider.ushealthgroup.com or call 866-745-8744 to speak with a customer service representative.
\n - Missing Group Number. Group Number is required to proceed with the search.
\n - Missing Plan Benefit Type. Plan Benefit Type is required to proceed with the search.
\n - Missing Plan Business Division Code. Plan Business Division Code is required to proceed with the search.
\n - Missing Network ID. Network ID is required to proceed with the search.
\n - Missing Plan Code. Plan Code is required to proceed with the search.
\n - Missing Plan Variation Code. Plan Variation Code is required to proceed with the search.
\n - Missing Plan Product Code. Plan Product Code is required to proceed with the search.
\n - Missing IPA Number. IPA Number is required to proceed with the search.
\n - Missing Source System Code. Source System Code is required to proceed with the search to get delegatedInfo.
\n - Missing serviceStartDt or serviceEndDt. serviceStartDt and serviceEndDt are required to proceed with the search.
\n - FirstName, LastName, MemberId and DateOfBirth is mandatory when Policy number is available.
\n - Member not found.
\n - Member not found – Empty response from Identity backend service.
\n - Member not found - Partial response.
\n - Member not found - Policy unavailable.
\n - Member not found - No Data Found in backend service.
\n - Member not found - No Data found for the selected date range search.
\n - Multiple Member found - Please refine your search.
\n - Query Validation Error.
\n - No member found.
\n - No Policy found in the given date range.
\n - This plan is administered by a different payer. The payer ID is {payer ID}. (Non-AARP)
\n - This plan is administered by a different payerId. (For AARP)
\n - Member not found - General Exception.
\n - Found Multiple Identity API Identifier.
\n - This plan is administered by USN01.Please confirm Payer Name/Payer ID and resubmit your request for quickest results.
\n
\n \n - MISSING_REQUIRED_FIELD\n
\n - Missing mandatory header field:XXXXX
\n - Missing mandatory required field:XXXXX
\n
\n \n - INVALID_FIELD\n
\n - Invalid date format, please submit yyyy-MM-dd format
\n - unsupported Payer ID,please verify and re-submit
\n
\n \n - INTERNAL_SERVER_ERROR\n
\n - System Unavailable at this time. Please try again later
\n
\n \n - BAD_USER_INPUT\n
\n - Variable \"$benChkInput\" got invalid value { beneficiaryId: \"123456\", dateOfBirth: \"1976-08-27\", firstName: \"\", lastNamee: \"\", groupNumber: \"NMOFEX\", familyIndicator: \"Y\", serviceStartDate: \"2024-01-20\", serviceEndDate: \"2024-01-20\" } at \"benChkInput.beneficiaryDetail\"; Field \"lastNamee\" is not defined by type \"BeneficiaryDetailInput\". Did you mean \"lastName\" or \"firstName\"?
\n
\n \n
\n
\nPlanBenefitCategory\n\n - VALIDATION_FAILED\n
\n - Invalid transaction id
\n - One of the mandatory field(s) is passed as blank in the request
\n - No Policy Found
\n - No Members Found.
\n - Invalid benefitId.
\n - B360 Summary Benefit Categories not found.
\n - Benefit Category not found.
\n - The date is not in a valid format. Please enter it in the yyyy-MM-dd format
\n - Bad request or missing required parameters in request
\n - No unique member found and unable to derive platform
\n - Multiple Members Found. Please refine Search
\n - Unknown or unsupported Platform. Please review your search criteria, including the Payer Name/Payer ID, and try again
\n - No members found for the given Member ID and Date of birth
\n - UHG Employee data - no access allowed to UHG intake user
\n - UHG Employee data - no access allowed to UHG internal user
\n - Please contact the United HealthCare Global customer service number on the back of the member's ID card or at 800-718-1293
\n - Bad request - missing mandatory attributes
\n - Invalid NPI
\n - Invalid TIN
\n - Bad request or Internal server error while fetching consumer data
\n - Bad request, blocked payer, dynamic error message from exception
\n - Bad request, blocked Cirrus payer, dynamic error message from exception
\n - This plan is administered by USN01. Please confirm Payer Name/Payer ID and resubmit your request for quickest results
\n - Dynamic error response from response body, related to bad request
\n - Invalid provider information
\n - Last Date of Service must be on or after the First Date of Service
\n - Multiple patients found for the given search criteria. Please enter the patient's Member ID number to get a unique result
\n - Date of Birth must be on or before the Date of Service
\n - Your search exceeds the date of service parameters for this plan. Plans are required to respond back for at least 18 months in the past and until the end of the current month. Please revise your Date of Service selections
\n - The date of birth you entered does not match our records. Please review your search criteria, including the Payer Name/Payer ID, and try again
\n - Please enter a valid Member ID
\n - A duplicate record was found, please change your search type to include the patient's first name
\n - Your search returned no results. Please review your search criteria, including the Payer Name/Payer ID, and try again
\n - A duplicate record was found, please change your search type to include the patient's first name or member ID
\n - Member eligibility is currently on hold and we are unable to process your request at this time. Please try again later
\n - An unexpected system error occurred while processing your request, please try your search again
\n - This plan is administered by a different payer. The payer ID is <payer ID>. (Non-AARP)
\n - This plan is administered by a different payer. (For AARP)
\n - Last Date of Service must be on or after the First Date of Service
\n - Multiple members found in the retrigger response
\n - No active policy found in the retrigger response
\n - No data found for the given NPI/TIN Combination
\n - Member was found, but there is no active coverage for the searched Dates of Service. Please enter new Dates of service and resubmit
\n - No matching Benefits found for searched phrase
\n - The date is not in a valid format. Please enter it in the yyyy-MM-dd format.
\n
\n \n - PARTIAL_DATA_RECEIVED\n
\n - Your search returned no policies; however, policies were found outside of the entered date range. Please update the service dates and try again
\n
\n \n - MISSING_REQUIRED_FIELD\n
\n - Missing mandatory header field: XXXXX
\n - Missing mandatory required field: XXXX
\n
\n \n - INVALID_FIELD\n
\n - Invalid date format, please submit yyyy-MM-dd format
\n
\n \n - INTERNAL_SERVER_ERROR\n
\n - System Unavailable at this time. Please try again later
\n
\n \n - BAD_USER_INPUT\n
\n - Variable \"$benChkInput\" got invalid value { beneficiaryId: \"123456\", dateOfBirth: \"1976-08-27\", firstName: \"\", lastNamee: \"\", groupNumber: \"NMOFEX\", familyIndicator: \"Y\", serviceStartDate: \"2024-01-20\", serviceEndDate: \"2024-01-20\" } at \"benChkInput.beneficiaryDetail\"; Field \"lastNamee\" is not defined by type \"BeneficiaryDetailInput\". Did you mean \"lastName\" or \"firstName\"?
\n
\n \n
\n
\nPlanBenefitLanguage\n\n - VALIDATION_FAILED\n
\n - Invalid transaction id
\n - One of the mandatory field(s) is passed as blank in the request
\n - No Policy Found
\n - No Members Found.
\n - Invalid benefitCode.
\n - B360 Detail Benefit Section not found.
\n - Benefit Category not found.
\n - The date is not in a valid format. Please enter it in the yyyy-MM-dd format.
\n - Additional coverage response failure
\n
\n \n - MISSING_REQUIRED_FIELD\n
\n - Missing mandatory header field: XXXXX
\n - Missing mandatory required field: XXXXX
\n - Either of Member data attributes or eligibilityTransactionId is required input
\n
\n \n - INVALID_FIELD\n
\n - Invalid date format, please submit yyyy-MM-dd format
\n
\n \n - INTERNAL_SERVER_ERROR\n
\n - System Unavailable at this time. Please try again later
\n - Stargate level Authorization failure.
\n
\n \n - BAD_USER_INPUT\n
\n - Variable \"$benChkInput\" got invalid value { beneficiaryId: \"123456\", dateOfBirth: \"1976-08-27\", firstName: \"\", lastNamee: \"\", groupNumber: \"NMOFEX\", familyIndicator: \"Y\", serviceStartDate: \"2024-01-20\", serviceEndDate: \"2024-01-20\" } at \"benChkInput.beneficiaryDetail\"; Field \"lastNamee\" is not defined by type \"BeneficiaryDetailInput\". Did you mean \"lastName\" or \"firstName\"?
\n
\n \n
\n"},"400":{"content":{"application/json":{"examples":{"Schema Validation Errors":{"summary":"Schema Validation Errors","value":{"errors":[{"code":"GRAPHQL_VALIDATION_FAILED","description":"Cannot query field \"serviceOutcomeCode\" on type \"matchedPriorAuths\""}]}}},"schema":{"type":"object","properties":{"data":{"type":"object","properties":{"checkPlanBenefitLanguage":{"$ref":"#/components/schemas/BenefitLanguageResponse"},"checkPriorAuthBenefitCoverage":{"$ref":"#/components/schemas/BenefitCheckResponse"},"checkPlanBenefitCategory":{"$ref":"#/components/schemas/BenefitCategoryResponse"},"referralInquiry":{"$ref":"#/components/schemas/ReferralInquiryResponse"}}},"errors":{"items":{"type":"object","properties":{"code":{"type":"string","description":"Error code identifying the specific error"},"description":{"type":"string","description":"Detailed error message"}}},"description":"List of errors if occurred during Benefit Check","type":"array"}}}}},"description":"\n - GRAPHQL_VALIDATION_FAILED\n
\n - Cannot query field on type
\n
\n \n - GRAPHQL_PARSE_FAILED\n
\n - Syntax Error: Unexpected }
\n
\n \n
\n"},"401":{"content":{"application/json":{"examples":{"Invalid authentication token":{"summary":"Invalid authentication token","value":{"message":"Authentication failed: Invalid or expired token"}}}}},"description":"Authentication failed: Invalid or expired token"},"500":{"content":{"application/json":{"examples":{"General server error":{"summary":"General server error","value":{"errors":[{"code":"INTERNAL_SERVER_ERROR","description":"An unexpected error occurred while processing the request"}]}}},"schema":{"type":"object","properties":{"errors":{"type":"array","items":{"type":"object","properties":{"code":{"type":"string"},"description":{"type":"string"}}}}}}}},"description":"Internal server error - Problem occurred on the server"},"504":{"content":{"application/json":{"examples":{"General server error":{"summary":"General server error","value":{"message":"System Unavailable at this time. Please try again later"}}},"schema":{"type":"object","properties":{"message":{"type":"string","description":"Error message"}}}}},"description":"504 Gateway Time-out"}}}}},"components":{"schemas":{"BenefitCheckResponseDataWrapper":{"type":"object","properties":{"data":{"description":"Benefit Check response wrapper.","$ref":"#/components/schemas/BenefitCheckResponseWrapper"}},"description":"Benefit Check response data wrapper."},"BenefitCheckInputDTO":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"serviceLocation":{"description":"Service Location","$ref":"#/components/schemas/ServiceLocationInput"},"caseDetailProvider":{"description":"Case Detail Provider","items":{"$ref":"#/components/schemas/CaseDetailProviderInput"},"type":"array"},"diagnosisCodes":{"description":"Diagnosis codes","items":{"$ref":"#/components/schemas/DiagnosisCodesInput"},"type":"array"},"facilityServiceDetail":{"description":"Facility service detail","$ref":"#/components/schemas/FacilityServiceDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"BenefitCheckInputDTO"},"ReferralInquiryResponseDataWrapper":{"type":"object","properties":{"data":{"description":"Referral Inquiry response wrapper.","$ref":"#/components/schemas/ReferralInquiryResponseWrapper"}},"description":"Referral Inquiry response data wrapper."},"ReferralInquiryInputDTO":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"providerDetail":{"description":"Details of the provider","$ref":"#/components/schemas/ProviderDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"Input for checking referral requirements."},"BenefitLanguageResponseDataWrapper":{"type":"object","properties":{"data":{"description":"Benefit Language response wrapper.","$ref":"#/components/schemas/BenefitLanguageResponseWrapper"}},"description":"Benefit Language response data wrapper."},"BenefitLanguageInputDTO":{"type":"object","properties":{"beneficiaryDetail":{"description":"Transaction ID from eligibility or benefit category lookup.","$ref":"#/components/schemas/BeneficiaryDetailInput"},"eligibilityTransactionId":{"description":"Transaction ID returned from eligibility or Benefit Category operation (Conditionally Required)","example":"abcdefg","type":"string"},"benefitId":{"description":"Benefit Id","example":"ben-a111-b222-c333","type":"string"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"BenefitLanguageInputDTO"},"BenefitCategoryResponseDataWrapper":{"type":"object","properties":{"data":{"description":"Benefit Category response wrapper.","$ref":"#/components/schemas/BenefitCategoryResponseWrapper"}},"description":"Benefit Category response data wrapper."},"BenefitCategoryInputDTO":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"searchPhrase":{"description":"Search Phrase","example":"MRI","type":"string"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"Input for retrieving plan benefit categories."},"ServiceOutcome":{"type":"object","properties":{"procedureCode":{"description":"cpt/hcpcs service procedure code","example":"98941","type":"string"},"procedureCodeDescription":{"description":"Description of the procedure code","example":"Chiropractic adjustment involving 3-4 areas of the spine","type":"string"},"servicePriorAuth":{"description":"Prior authorization details for the service","$ref":"#/components/schemas/ServicePriorAuth"}},"description":"Outcome details for a requested service"},"BenefitDetail":{"type":"object","properties":{"benefitId":{"description":"Unique identifier for the benefit sub-category.","example":"abc2fe-89b57","type":"string"},"benefitName":{"description":"Name of the benefit sub-category.","example":"X-Ray","type":"string"},"benefitSummaryText":{"description":"Summary text explaining the benefit.","example":"UnitedHealthcare X-Ray Program","type":"string"}},"description":"Details of a specific benefit."},"ProviderDetailInput":{"type":"object","properties":{"providerLastOrOrganizationName":{"description":"Provider Last Name or Organization Name","example":"Doe Clinic","type":"string"},"providerFirstName":{"description":"Provider (physician) First Name. Optional for facility/institutional provider","example":"John","type":"string"},"providerNPI":{"description":"National Provider Identifier","example":"9876543210","type":"string"}},"required":["providerLastOrOrganizationName"],"description":"Details of the provider for referral inquiry."},"CaseOutcome":{"type":"object","properties":{"casePriorAuth":{"description":"Prior authorization details for the case","$ref":"#/components/schemas/CasePriorAuth"}},"description":"Outcome details for the benefit check case"},"CasePriorAuth":{"type":"object","properties":{"requestMessages":{"description":"Messages related to the prior authorization request","items":{"$ref":"#/components/schemas/Message"},"type":"array"},"requestOutcomeCode":{"description":"prior auth case outcome code (valid values:-1/2/3/4/5)","example":"1","type":"string"},"requestOutcomeCodeDescription":{"description":"Description of the outcome code","example":"Authorization Required","type":"string"},"requestReferenceNumber":{"description":"unique payer identifier assigned to prior auth case","example":"REQ123456789","type":"string"}},"description":"Details of the prior authorization request"},"ProviderRoleInput":{"type":"object","properties":{"role":{"description":"Role of the provider (BI:Billing/Requesting; AT:Attending; SF:Servicing; FA:Facility)","example":"Requesting","type":"string"}},"required":["role"],"description":"Role of the provider in the case."},"FacilityServiceDetailInput":{"type":"object","properties":{"facilityServiceStartDate":{"description":"First date of service or admission date. The Facility start date will default to the current date. Services can be performed any time during this date range.","example":"2025-08-01","type":"string"},"facilityServiceEndDate":{"description":"Last date of service or discharge date. The Facility end date will default to 90 Days after the Facility Start Date. Services can be performed any time during this date range.","example":"2025-08-01","type":"string"},"isPatientAdmitted":{"description":"Boolean flag if patient is admitted. Required when OPF or IP, Optional for OP","example":false,"type":"boolean"},"isPatientDischarged":{"description":"Boolean flag if patient is discharged. Required when OPF or IP, Optional for OP","example":false,"type":"boolean"}},"required":["facilityServiceStartDate","facilityServiceEndDate"],"description":"Details of the facility service."},"CaseService":{"type":"object","properties":{"procedureCode":{"description":"Procedure code for which the prior auth was submitted","example":"99213","type":"string"},"serviceDecision":{"description":"Decision for the service.","example":"Approved","type":"string"},"serviceMessage":{"description":"Message related to the service decision.","example":"Prior authorization valid through 2025-12-31","type":"string"}},"description":"Details of a service in a matched prior authorization case"},"CaseDetailProviderInput":{"type":"object","properties":{"providerType":{"description":"Provider entity type (Physician, Facility, Allied Ancillary)","example":"Physician","type":"string"},"providerTaxIdNumber":{"description":"Provider tax identification number","example":"123456789","type":"string"},"providerNPI":{"description":"National Provider Identifier","example":"9876543210","type":"string"},"providerFirstName":{"description":"Provider first name (Required for Physician, Conditional for Facility)","example":"John","type":"string"},"providerLastOrOrganizationName":{"description":"Provider Last Name or Organization Name","example":"Doe Clinic","type":"string"},"address":{"description":"Address of the provider","$ref":"#/components/schemas/AddressInput"},"providerRoles":{"description":"Provider Role inputs","items":{"$ref":"#/components/schemas/ProviderRoleInput"},"type":"array"},"procedureDetails":{"description":"Procedure Detail Input","items":{"$ref":"#/components/schemas/ProcedureDetailsInput"},"type":"array"}},"required":["address.line1","address.city","address.state","address.zip","procedureDetails[].procedureCode","procedureDetails[].diagnosisCode","procedureDetails[].serviceDetailDescription","providerRoles[].role","providerType","providerTaxIdNumber","providerNPI","providerLastOrOrganizationName","address","providerRoles","procedureDetails"],"description":"Details of the provider involved in the case."},"AddressInput":{"type":"object","properties":{"line1":{"description":"First line of street address","example":"1234 CHARDAVE","type":"string"},"line2":{"description":"Second line of street address","type":"string"},"city":{"description":"City","example":"Hastings","type":"string"},"state":{"description":"State code","example":"TX","type":"string"},"zip":{"description":"ZIP code","example":"12133","type":"string"},"zip4":{"description":"Extended ZIP+4 code","example":"1001","type":"string"}},"required":["line1","city","state","zip"],"description":"Address of the provider."},"CheckPriorAuthBenefitCoverage":{"type":"object","properties":{"caseOutcome":{"description":"Outcome of the benefit check case including prior authorization details","$ref":"#/components/schemas/CaseOutcome"},"caseSummary":{"description":"Summary of the case including member and provider details","$ref":"#/components/schemas/CaseSummary"},"matchedPriorAuths":{"description":"List of matched prior authorization cases","items":{"$ref":"#/components/schemas/MatchedPriorAuths"},"type":"array"},"serviceOutcomes":{"description":"List of outcomes for each requested service","items":{"$ref":"#/components/schemas/ServiceOutcome"},"type":"array"}},"description":"Response type for Benefit Check operation"},"ProcedureDetailsInput":{"type":"object","properties":{"procedureCode":{"description":"Procedure code","example":"99213","type":"string"},"codeType":{"description":"Procedure Code type (CPT/HCPCS).","example":"CPT","type":"string"},"isPrimary":{"description":"Indicates if the procedure code is primary.","example":true,"type":"boolean"},"serviceStartDate":{"description":"Expected start date of the procedure. Conditional for IP/OPF.Required for OP","example":"2025-08-01","type":"string"},"serviceEndDate":{"description":"If applicable, a physician order may be required for the requested service dates. Conditional for IP/OPF.Required for OP","example":"2025-08-01","type":"string"},"diagnosisCode":{"description":"Diagnosis code related to the service.","example":"J01.90","type":"string"},"procedureUnitPerFrequencyCount":{"description":"The number of times in the specified frequency time span the procedure will occur. Conditional for IP/OPF.Required for OP","example":"1","type":"string"},"procedureUnitOfMeasure":{"description":"The assigned unit value of a particular CPT or HCPCS code (MJ=Minutes; UN=Units). Conditional for IP/OPF.Required for OP.","example":"UN","type":"string"},"procedureFrequency":{"description":"The rate at which the Count can be billed during the date range (1=Weekly; 4=Monthly; 6=Daily). Conditional for IP/OPF.Required for OP","example":"1","type":"string"},"procedureUnitCount":{"description":"Procedure unit count. Conditional for IP/OPF.Required for OP","example":"1","type":"string"},"procedureBilledChargeAmount":{"description":"Line item charge amount for the service.","example":"100","type":"string"},"serviceDetailDescription":{"description":"Description of the nature of the service.","example":"Medical","type":"string"}},"required":["procedureCode","diagnosisCode","serviceDetailDescription"],"description":"Details of the procedure being checked."},"BenefitCategoryResponseWrapper":{"type":"object","properties":{"checkPlanBenefitCategory":{"description":"Benefit Category response","$ref":"#/components/schemas/CheckPlanBenefitCategory"}},"description":"Benefit Category response wrapper."},"ServicePriorAuth":{"type":"object","properties":{"isPriorAuthOnFile":{"description":"boolean field to suggest if an existing prior auth is found for the procedure code","example":false,"type":"boolean"},"messages":{"description":"Message related to the request outcome","items":{"$ref":"#/components/schemas/Message"},"type":"array"},"serviceOutcomeCode":{"description":"prior auth outcome code at service level (valid values:-1/2/3/4/5)","example":"1","type":"string"}},"description":"Prior authorization details for a service"},"BenefitCheckResponseWrapper":{"type":"object","properties":{"checkPriorAuthBenefitCoverage":{"description":"Benefit Check response","$ref":"#/components/schemas/CheckPriorAuthBenefitCoverage"}},"description":"Benefit Check response wrapper."},"CaseSummary":{"type":"object","properties":{"member":{"description":"Member information","$ref":"#/components/schemas/Member"},"placeOfServiceCode":{"description":"place of service code (edi837 compliant two byte value)","example":"11","type":"string"},"requestingProviderNPI":{"description":"NPI of the requesting provider","example":"9876543210","type":"string"},"requestingProviderTin":{"description":"Tax ID of the requesting provider","example":"123456789","type":"string"}},"description":"Summary of the benefit check case"},"BeneficiaryDetailInput":{"type":"object","properties":{"beneficiaryId":{"description":"Unique identifier for the patient/member","example":"M123456789","type":"string"},"dateOfBirth":{"description":"Date of birth of the patient","example":"1985-06-15","type":"string"},"firstName":{"description":"Patient first name","example":"John","type":"string"},"lastName":{"description":"Patient last name","example":"Doe","type":"string"},"groupNumber":{"description":"Group or Member Policy Number","example":"G123456","type":"string"},"serviceStartDate":{"description":"First date of service; Default is current date","example":"2023-01-01","type":"string"},"serviceEndDate":{"description":"End date of service; Default is current date","example":"2023-01-01","type":"string"}},"required":["beneficiaryId","dateOfBirth","firstName","lastName","groupNumber"],"description":"Details of the member for benefit check."},"ReferralInquiry":{"type":"object","properties":{"referralIndicator":{"description":"referral indicator to describe if referral is required or not for the member policy/plan","example":"Y","type":"string"}},"description":"Response indicating whether a referral is required for the member's plan."},"BenefitLanguage":{"type":"object","properties":{"benefitName":{"description":"Name of the benefit.","example":"Hearing Aids","type":"string"},"benefitDetails":{"description":"Detailed explanation of the benefit.","example":"What are hearing aids: Electronic amplifying devices designed to bring sound more effectively into the ear.","type":"string"},"benefitInformationSection":{"description":"Informational data for the benefitId","example":"text","items":{"type":"string"},"type":"array"},"benefitNetworkSection":{"description":"Network-specific cost and coverage details.","items":{"$ref":"#/components/schemas/BenefitNetworkSection"},"type":"array"},"limitsAndExceptions":{"description":"Limitations and exceptions applicable to the benefit.","items":{"$ref":"#/components/schemas/LimitException"},"type":"array"}},"description":"Language details of a benefit including costs, network status, and exceptions."},"BenefitNetworkSection":{"type":"object","properties":{"costs":{"description":"cost details for the benefit","example":"UHC Network: co-insurance after you pay the deductible. Is prior-auth needed? No","type":"string"},"networkStatus":{"description":"network status details on the benefit","example":"Your cost if you use Network benefits","items":{"type":"string"},"type":"array"}},"description":"Details of benefit coverage within a specific network."},"ServiceLocationInput":{"type":"object","properties":{"placeOfServiceCode":{"description":"CLM05-01 [Place of Service Code or Bill Type Code] from EDI837. Code identifying where services were, or may be, performed.","example":"11","type":"string"},"claimType":{"description":"Code identifying the type of facility referenced (I=Instituitional, P=Professional or D=Dental","example":"I","type":"string"},"serviceDetail":{"description":"Describes the nature of the service","example":"Medical","type":"string"},"serviceDescription":{"description":"Describes the nature of the service (Scheduled, Emergent or Urgent)","example":"Scheduled","type":"string"}},"required":["placeOfServiceCode","claimType","serviceDetail","serviceDescription"],"description":"Location and type of service."},"MatchedPriorAuths":{"type":"object","properties":{"caseDecision":{"description":"decision outcome on the matching prior auth existing in the system","example":"Approved","type":"string"},"caseServices":{"description":"List of services included in the matched prior authorization case","items":{"$ref":"#/components/schemas/CaseService"},"type":"array"},"caseStatus":{"description":"current status of the existing prior auth","example":"Closed","type":"string"},"serviceReferenceNumber":{"description":"prior auth reference number for an existing matched prior auth submitted by the provider for the member","example":"AUTH123456","type":"string"}},"description":"Details of matched prior authorization cases"},"Member":{"type":"object","properties":{"groupNumber":{"description":"Group or policy number of the member","example":"M123456789","type":"string"},"memberId":{"description":"Unique identifier for the member","example":"G123456","type":"string"}},"description":"Member information"},"DiagnosisCodesInput":{"type":"object","properties":{"diagnosisTypeCode":{"description":"Diagnosis type code (ex:ABK/ABJ for Primary ICD10 and BK/BJ for Primary ICD9; ABF/APR for Secondary ICD10 and BF/BR for Secondary ICD9)","example":"ABK","type":"string"},"diagnosisCode":{"description":"Diagnosis Code example J01.90","example":"J01.90","type":"string"}},"required":["diagnosisTypeCode","diagnosisCode"],"description":"Diagnosis codes relevant to the case."},"BenefitLanguageResponseWrapper":{"type":"object","properties":{"checkPlanBenefitLanguage":{"description":"Benefit Language response","$ref":"#/components/schemas/CheckPlanBenefitLanguage"}},"description":"Benefit Language response wrapper."},"Message":{"type":"object","properties":{"messageText":{"description":"Text of the message","example":"Prior authorization required for the requested service","type":"string"}},"description":"Message related to prior authorization or service outcome"},"CheckPlanBenefitCategory":{"type":"object","properties":{"eligibilityTransactionId":{"description":"transaction id returned on the previous eligibility lookup (valid only for certain timeperiod)","example":"abcdefg","type":"string"},"newBenefits":{"description":"boolean value:- true=>Benefit Language can be called for further details; false=>Benefit Language not supported.","example":true,"type":"boolean"},"benefitCategory":{"description":"List of benefit categories.","items":{"$ref":"#/components/schemas/BenefitCategory"},"type":"array"}},"description":"Response containing benefit categories available to the member."},"BenefitCategory":{"type":"object","properties":{"categoryName":{"description":"Parent category of the benefit.","example":"MRI services","type":"string"},"categoryDetail":{"description":"Details of the benefit sub-category.","items":{"$ref":"#/components/schemas/BenefitDetail"},"type":"array"}},"description":"Benefit category and its details."},"LimitException":{"type":"object","properties":{"description":{"description":"Summary of the limitation or exception.","example":"General","type":"string"},"details":{"description":"Detailed explanation of the limitation or exception.","example":"No coverage for bone anchored hearing aids except Craniofacial anomalies.","type":"string"}},"description":"Limitations and exceptions for a benefit."},"ReferralInquiryResponseWrapper":{"type":"object","properties":{"referralInquiry":{"description":"Referral Inquiry response","$ref":"#/components/schemas/ReferralInquiry"}},"description":"Referral Inquiry response wrapper."},"CheckPlanBenefitLanguage":{"type":"object","properties":{"newBenefits":{"description":"boolean value:- true=>Benefit Language can be called for further details; false=>Benefit Language not supported.","example":true,"type":"boolean"},"benefits":{"description":"Detailed benefit language including cost shares, limits, and exceptions.","$ref":"#/components/schemas/BenefitLanguage"}},"description":"Response containing language details for a specific benefit."},"BenefitCheckInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"serviceLocation":{"description":"Service Location","$ref":"#/components/schemas/ServiceLocationInput"},"caseDetailProvider":{"description":"Case Detail Provider","items":{"$ref":"#/components/schemas/CaseDetailProviderInput"},"type":"array"},"diagnosisCodes":{"description":"Diagnosis codes","items":{"$ref":"#/components/schemas/DiagnosisCodesInput"},"type":"array"},"facilityServiceDetail":{"description":"Facility service detail","$ref":"#/components/schemas/FacilityServiceDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"BenefitCheckInputDTO"},"ReferralInquiryInput":{"type":"object","properties":{"beneficiaryDetail":{"description":"Details of the beneficiary","$ref":"#/components/schemas/BeneficiaryDetailInput"},"providerDetail":{"description":"Details of the provider","$ref":"#/components/schemas/ProviderDetailInput"},"payerId":{"description":"Payer Id","example":"12345","type":"string"}},"description":"Input for checking referral requirements."},"BenefitCheckResponse":{"type":"object","properties":{"data":{"description":"Benefit Check response wrapper.","$ref":"#/components/schemas/BenefitCheckResponseWrapper"}},"description":"Benefit Check response data wrapper."},"ReferralInquiryResponse":{"type":"object","properties":{"data":{"description":"Referral Inquiry response wrapper.","$ref":"#/components/schemas/ReferralInquiryResponseWrapper"}},"description":"Referral Inquiry response data wrapper."},"BenefitLanguageResponse":{"type":"object","properties":{"data":{"description":"Benefit Language response wrapper.","$ref":"#/components/schemas/BenefitLanguageResponseWrapper"}},"description":"Benefit Language response data wrapper."},"BenefitCategoryResponse":{"type":"object","properties":{"data":{"description":"Benefit Category response wrapper.","$ref":"#/components/schemas/BenefitCategoryResponseWrapper"}},"description":"Benefit Category response data wrapper."}},"securitySchemes":{"oAuth":{"type":"oauth2","description":"This API uses OAuth 2 with the client_credentials grant flow.","flows":{"clientCredentials":{"tokenUrl":"/apip/auth/sntl/v1/token","scopes":{"read_txn":"read transactions","create_txn":"submit a new transaction request","read_coveragediscovery":"read coverage discovery tasks","create_coveragediscovery":"submit a new coverage discovery task","read_healthcheck":"check the status of the system"}}}}}},"x-readme":{"explorer-enabled":true,"proxy-enabled":true}}